Adherence with brand versus generic bisphosphonates among osteoporosis patients: a new-user cohort study in the French National Healthcare Insurance database.

Several studies documented declines in treatment adherence with generic forms of oral bisphosphonates in osteoporosis compared to branded forms, while others did not support this relation. Our aim was to compare medication adherence with brand versus generic forms of oral bisphosphonates. A new-user cohort study was conducted using routinely collected administrative and healthcare data linked at the individual level extracted from a nationwide representative sample of the French National Healthcare Insurance database. We included all patients aged 50 and older, new users of oral bisphosphonates for primary osteoporosis between 01/01/2009 and 31/12/2015. Two components of adherence were measured: implementation (continuous multiple-interval measure of medication availability version 7; CMA7) and persistence (time to discontinuation). The sample was composed of 1,834 in the "brand bisphosphonate" group and 1,495 patients in the "generic bisphosphonate" group. Initiating oral bisphosphonate treatment with brand was associated with a higher risk of discontinuation within 12 months (Hazard Ratio = 1.08; 95%CI = [1.02;1.14]). The risk of good implementation (CMA7 ≥ 0.90) was significantly lower in "brand bisphosphonate" group (Risk Ratio = 0.90; 95%CI = [0.85; 0.95]). We did not find any evidence to support the hypothesis of a lower adherence to generic bisphosphonates. In fact, prescribing of generic bisphosphonates led to a higher persistence rate and to better implementation at 1 year.

Effect of data validation audit on hospital mortality ranking and pay for performance.

BACKGROUND: Quality improvement and epidemiology studies often rely on database codes to measure performance or impact of adjusted risk factors, but how validity issues can bias those estimates is seldom quantified. OBJECTIVES: To evaluate whether and how much interhospital administrative coding variations influence a typical performance measure (adjusted mortality) and potential incentives based on it. DESIGN: National cross-sectional study comparing hospital mortality ranking and simulated pay-for-performance incentives before/after recoding discharge abstracts using medical records. SETTING: Twenty-four public and private hospitals located in France PARTICIPANTS: All inpatient stays from the 78 deadliest diagnosis-related groups over 1 year. INTERVENTIONS: Elixhauser and Charlson comorbidities were derived, and mortality ratios were computed for each hospital. Thirty random stays per hospital were then recoded by two central reviewers and used in a Bayesian hierarchical model to estimate hospital-specific and comorbidity-specific predictive values. Simulations then estimated shifts in adjusted mortality and proportion of incentives that would be unfairly distributed by a typical pay-for-performance programme in this situation. MAIN OUTCOME MEASURES: Positive and negative predictive values of routine coding of comorbidities in hospital databases, variations in hospitals' mortality league table and proportion of unfair incentives. RESULTS: A total of 70 402 hospital discharge abstracts were analysed, of which 715 were recoded from full medical records. Hospital comorbidity-level positive predictive values ranged from 64.4% to 96.4% and negative ones from 88.0% to 99.9%. Using Elixhauser comorbidities for adjustment, 70.3% of hospitals changed position in the mortality league table after correction, which added up to a mean 6.5% (SD 3.6) of a total pay-for-performance budget being allocated to the wrong hospitals. Using Charlson, 61.5% of hospitals changed position, with 7.3% (SD 4.0) budget misallocation. CONCLUSIONS: Variations in administrative data coding can bias mortality comparisons and budget allocation across hospitals. Such heterogeneity in data validity may be corrected using a centralised coding strategy from a random sample of observations.

Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study.

OBJECTIVE: Matching healthcare staff resources to patient needs in the ICU is a key factor for quality of care. We aimed to assess the impact of the staffing-to-patient ratio and workload on ICU mortality. DESIGN: We performed a multicenter longitudinal study using routinely collected hospital data. SETTING: Information pertaining to every patient in eight ICUs from four university hospitals from January to December 2013 was analyzed. PATIENTS: A total of 5,718 inpatient stays were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used a shift-by-shift varying measure of the patient-to-caregiver ratio in combination with workload to establish their relationships with ICU mortality over time, excluding patients with decision to forego life-sustaining therapy. Using a multilevel Poisson regression, we quantified ICU mortality-relative risk, adjusted for patient turnover, severity, and staffing levels. The risk of death was increased by 3.5 (95% CI, 1.3-9.1) when the patient-to-nurse ratio was greater than 2.5, and it was increased by 2.0 (95% CI, 1.3-3.2) when the patient-to-physician ratio exceeded 14. The highest ratios occurred more frequently during the weekend for nurse staffing and during the night for physicians (p < 0.001). High patient turnover (adjusted relative risk, 5.6 [2.0-15.0]) and the volume of life-sustaining procedures performed by staff (adjusted relative risk, 5.9 [4.3-7.9]) were also associated with increased mortality. CONCLUSIONS: This study proposes evidence-based thresholds for patient-to-caregiver ratios, above which patient safety may be endangered in the ICU. Real-time monitoring of staffing levels and workload is feasible for adjusting caregivers' resources to patients' needs.